The GCC have made a number of statements over the past few months regarding the quality of evidence required to support public claims made by chiropractors. Following the publication of the Bronfort report in Feb 2010 the GCC set the required standard as one of moderate or high, positive quality evidence.
In an email from the GCC to myself, the GCC stated:
The GCC’s guidance to the profession mirrors that of the Committee of Advertising Practice Copy Advice Team ie that any claims for chiropractic must be based on best research of the highest quality. This will almost certainly mean randomised controlled trials that produce high or moderate quality positive evidence.
Notice the use of the phrase ‘any claims for chiropractic’, not just claims surrounding the actual treatment of specific conditions.
Anybody who has looked at the subject of chiropractic will have seen the term ‘subluxation’. Subluxations are at the very root of chiropractic treatments, according to chiropractors subluxations are the cause of many health worries (either directly or indirectly). Many chiropractors now refer to ‘misaligned joints or vertebra, rather than subluxation, but regardless of the terminology used they believe that treating the subluxation will treat the condition by allowing the body to heal itself. Furthermore in patients with no symptoms, regularly treating subluxations will help maintain a level of ‘wellness’. This is the basis on which most chiropractors offer treatments.
So you’d assume that something so fundamental to the chiropractic profession must be supported by some good evidence – right? Well (unsurprisingly), Wrong!
A recent review of the evidence for subluxations causing healthcare concerns can be found here: An epidemiological examination of the subluxation construct using Hill’s criteria of causation (Pub: Dec 2009)
The conclusions of the review are as follows:
Hill’s criteria are the most commonly used epidemiologic model for suggesting a causal link for any diagnostic or treatment approach. There is a significant lack of evidence in the literature to fulfil Hill’s criteria of causation with regards to the chiropractic subluxation. No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention. Regardless of popular appeal this leaves the subluxation construct in the realm of unsupported speculation. This lack of supportive evidence suggests the subluxation construct has no valid clinical applicability.
It’s worth having a look at table 3 of the report to see exactly how many studies they found that were of high enough quality: Table 3 The phrase ‘no studies’ would seem to suggest a distinct lack of evidence! You could almost say ‘not a jot’ !
So I decided that the GCC must know a thing or two about subluxations, I’d ask them their views. Their reply was short and to the point:
Thank you for your enquiry. The General Council has never considered the research evidence for the chiropractic vertebral subluxation complex..
That was it …… Well sorry GCC, must try harder !
Not happy with the response I contacted them again on 28 March explaining why I felt the GCC were in a position to provide some information.
In the past the GCC have provided expert witnesses who have commented on subluxations, they have had statements in their website FAQ and they encourage the teaching of subluxations.
Unil recently the GCC FAQ stated:
As used by chiropractors, the term ‘subluxation’ doesn’t mean something that poses any danger to you. A subluxation is the name given to a joint that does not function and/or move as well as it can. Alternatively, a chiropractor may say a joint is misaligned. This may influence the way the body functions. A chiropractic subluxation may not be seen on an x-ray because x-rays look for changes in the structure of joints, not problems with function and movement.
I pointed out that I did not believe it was possible for the GCC to state that a subluxation does not pose any danger, if they have never looked at the evidence.
As I’ve already mentioned, the subluxation is fundamental to chiropractic, so much so that it is a requirement for chiropractic degrees as detailed in the GCC’s own document GCC Criteria for the recognition of Degrees in Chiropractic, May 2007 . Page 7 covers the criteria for knowledge & skills that form the basis of chiropractic. Guidance notes for Programme outcome 4(a) list “vertebral subluxation-centred models”.
The GCC cannot encourage the teaching of subluxation models, and then when questioned maintain a neutral position surrounding the evidence to support treatments offered against their effects.
There are widespread public claims surrounding subluxations and this goes to show that within the UK chiropractic profession there is an underlying belief that the subluxation (joint misalignment) is the root cause of many healthcare problems and treatments are offered by chiropractors based on this assumption.
The latest evidence review does not support this belief and even if the GCC has not so far considered the research, this does not absolve them from their regulatory duties to ensure that claims are supported by reliable evidence and these claims are accurate, factual and verifiable.
Making these claims could therefore be seen to contravene the GCC COP guidance:
C1.6 – COP Effective from 8 December 2005 to 29 June 2010
C4 – COP Effective from 30 June 2010
The GCC were then asked to provide clear, unambiguous answers to the following questions
1. (my original email question) Can you tell me at what level the GCC currently view the evidence for chiropractic vertebral subluxation complex (High, Moderate, Inconclusive, positive or negative etc) with regards to causation of disease or health concerns ? Also if the evidence is considered to be of a positive nature, could you please provide details of the reports used to reach this conclusion.
2. Does the GCC intend to review the research evidence or seek any advice on these claims (ASA/CAP etc), including expected timescale?
3. Provide a statement on how these claims currently relate to the GCC’s Code of Practice?
3a. If considered to breach the COP: What advice would it give to its members?
3b. If not considered to breach the COP; On what justification?
4. What is a subluxation and can it do me harm? ( This is the question removed from the GCC’s FAQ)
Last week (7 April) I got a reply from the GCC. As of yet there is no reply to the 4 questions, but I have been assured answers will be provided.
There were a couple of interesting points in the letter, including a comment that in Feb 2010 the GCC took a policy decision that it would not publish any claims for chiropractic. That was the reason subluxation was removed from its FAQ. That would seem to be a way of future proofing themselves from any further complaints, but it shows a stunning lack of confidence in the evidence base for chiropractic.
On the subject of the inclusion of subluxations in the curriculum for chiropractic degrees they have said:
In September 2009 the GCC commissioned a review of these criteria. At the meeting scheduled for 13 April 2010, the GCC’s statutory Education Committee will be considering a report on the associated consultation. A copy of your letter has been circulated to all Committee members and the current providers of chiropractic degree programmes have been asked to provided details of
- How the chiropractic vertebral subluxation complex is covered in the detailed curriculum
- What relevant research they draw from
My questions will be answered once the GCC have had time to consider the advice from the Education Committee.
I hope that in considering the finding of this meeting the GCC keep in mind that the ‘relevant research’ the teaching colleges use will still need to meet the criteria of showing high or moderate, positive evidence in favour of any claims. If it doesn’t then not only is there no evidence base for the current claims on chiropractors websites and literature, but there is no basis for teaching subluxations!
I will follow up this post once I get answers to my questions. One thing is certain …. the response needs to go a little further than we have “never considered the research evidence”
Quick edit to add link to part 2 of this subject: